NUR600/NUR 600 Final Exam V1 |
Advanced Health Assess Q&A with
Rationale | William Paterson University
1. Which of the following findings is most concerning when assessing a skin lesion using the
ABCDE mnemonic?
A. A lesion with a diameter of 4 mm
B. A symmetric border along the perimeter
C. A lesion that has remained unchanged for years
D. Multiple colors or shades of brown and black
Correct Answer: D
Expert Explanation: The ABCDE mnemonic stands for Asymmetry, Border irregularity,
Color variation, Diameter greater than 6 mm, and Evolving. Color variation within a single
lesion is a significant red flag for melanoma. Identifying these characteristics early is
crucial for the timely diagnosis and treatment of skin cancer.
2. When performing a cardiac assessment, where is the best location to auscultate the mitral
valve?
A. Second right intercostal space
B. Second left intercostal space
C. Fifth left intercostal space at the midclavicular line
,D. Fourth left intercostal space
Correct Answer: C
Expert Explanation: The mitral valve is best auscultated at the apex of the heart, which is
found at the fifth left intercostal space. This location corresponds to the midclavicular line
where the heart’s apical impulse is typically felt. Auscultation at this site allows for the
clearest sound of the mitral valve closing during the cardiac cycle.
3. A patient presents with pain in the right upper quadrant that worsens with deep
inspiration during palpation. This is known as:
A. Murphy sign
B. Rovsing sign
C. McBurney point tenderness
D. Psoas sign
Correct Answer: A
Expert Explanation: A positive Murphy sign is indicated when a patient experiences sharp
pain and abruptly stops inhaling while the clinician palpates the gallbladder area. This
finding is highly suggestive of acute cholecystitis. In contrast, Rovsing and Psoas signs are
typically associated with appendicitis assessments.
4. During a neurological exam, the nurse asks the patient to shrug their shoulders against
resistance. Which cranial nerve is being evaluated?
A. Cranial Nerve XI (Spinal Accessory)
, B. Cranial Nerve X (Vagus)
C. Cranial Nerve IX (Glossopharyngeal)
D. Cranial Nerve XII (Hypoglossal)
Correct Answer: A
Expert Explanation: Cranial nerve XI, the spinal accessory nerve, innervates the trapezius
and sternocleidomastoid muscles. Shrugging the shoulders against resistance tests the
strength and integrity of the trapezius muscle. Assessment of this nerve also includes
checking the patient’s ability to turn their head against resistance.
5. Which physical exam technique is used to assess for the presence of fluid in the middle
ear?
A. Weber test
B. Rinne test
C. Whispered voice test
D. Otoscopic exam with pneumatic otoscopy
Correct Answer: D
Expert Explanation: Pneumatic otoscopy is the gold standard for assessing middle ear
effusion by observing the mobility of the tympanic membrane. When air is puffed into the
ear canal, a healthy eardrum should move visibly. Lack of movement suggests that fluid or
pressure is present behind the membrane.
Advanced Health Assess Q&A with
Rationale | William Paterson University
1. Which of the following findings is most concerning when assessing a skin lesion using the
ABCDE mnemonic?
A. A lesion with a diameter of 4 mm
B. A symmetric border along the perimeter
C. A lesion that has remained unchanged for years
D. Multiple colors or shades of brown and black
Correct Answer: D
Expert Explanation: The ABCDE mnemonic stands for Asymmetry, Border irregularity,
Color variation, Diameter greater than 6 mm, and Evolving. Color variation within a single
lesion is a significant red flag for melanoma. Identifying these characteristics early is
crucial for the timely diagnosis and treatment of skin cancer.
2. When performing a cardiac assessment, where is the best location to auscultate the mitral
valve?
A. Second right intercostal space
B. Second left intercostal space
C. Fifth left intercostal space at the midclavicular line
,D. Fourth left intercostal space
Correct Answer: C
Expert Explanation: The mitral valve is best auscultated at the apex of the heart, which is
found at the fifth left intercostal space. This location corresponds to the midclavicular line
where the heart’s apical impulse is typically felt. Auscultation at this site allows for the
clearest sound of the mitral valve closing during the cardiac cycle.
3. A patient presents with pain in the right upper quadrant that worsens with deep
inspiration during palpation. This is known as:
A. Murphy sign
B. Rovsing sign
C. McBurney point tenderness
D. Psoas sign
Correct Answer: A
Expert Explanation: A positive Murphy sign is indicated when a patient experiences sharp
pain and abruptly stops inhaling while the clinician palpates the gallbladder area. This
finding is highly suggestive of acute cholecystitis. In contrast, Rovsing and Psoas signs are
typically associated with appendicitis assessments.
4. During a neurological exam, the nurse asks the patient to shrug their shoulders against
resistance. Which cranial nerve is being evaluated?
A. Cranial Nerve XI (Spinal Accessory)
, B. Cranial Nerve X (Vagus)
C. Cranial Nerve IX (Glossopharyngeal)
D. Cranial Nerve XII (Hypoglossal)
Correct Answer: A
Expert Explanation: Cranial nerve XI, the spinal accessory nerve, innervates the trapezius
and sternocleidomastoid muscles. Shrugging the shoulders against resistance tests the
strength and integrity of the trapezius muscle. Assessment of this nerve also includes
checking the patient’s ability to turn their head against resistance.
5. Which physical exam technique is used to assess for the presence of fluid in the middle
ear?
A. Weber test
B. Rinne test
C. Whispered voice test
D. Otoscopic exam with pneumatic otoscopy
Correct Answer: D
Expert Explanation: Pneumatic otoscopy is the gold standard for assessing middle ear
effusion by observing the mobility of the tympanic membrane. When air is puffed into the
ear canal, a healthy eardrum should move visibly. Lack of movement suggests that fluid or
pressure is present behind the membrane.
